Healthcare Provider Details

I. General information

NPI: 1578633954
Provider Name (Legal Business Name): NYASHA PAMELA MARIE BONNER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

IV. Provider business mailing address

80 JESSE HILL JR DR SE STE 10E005D
ATLANTA GA
30303-3031
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-5610
  • Fax:
Mailing address:
  • Phone: 404-489-9015
  • Fax: 404-489-9238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704158472
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5011349
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number255825
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN126828
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN126828
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: